The Republican efforts to repeal and replace Obamacare have been stalled due to the devastating report from the Congressional Budget Office showing that 22 million people would lose health care coverage. Only 12 percent of Americans back the plan according to a USA TODAY/Suffolk University Poll. They did find considerable consensus that any health care plan include the following:

Pre-existing conditions: More than three-fourths, 77%, say it is “very important” that the health care system permit people with pre-existing medical conditions to buy health insurance at the same price as others. Just 6% say that protection isn’t important to them. The Senate bill requires insurers to accept those with pre-existing conditions, but it allows states to seek permission to reduce required benefits. Some patients could face dramatically higher costs or lifetime limits for treatments no longer defined as essential.

Medicaid expansion: Nearly two-thirds, 63%, say it is “very important” that lower-income people who became eligible for Medicaid through the Affordable Care Act continued to be covered by Medicaid. Just 10% say that isn’t important to them. The nonpartisan Congressional Budget Office estimates that the Senate plan, which would cut Medicaid spending by $772 billion over the next 10 years, would result in 15 million fewer people being covered.

Lower premiums: Close to six in 10, 57%, say it is “very important” that insurance premiums go down in price; 17% say that’s not important. The CBO predicts that premiums would rise for a few years under the Senate plan, then fall by about 30%. But overall health care costs would go up for most people because deductibles would be higher and some states wouldn’t require insurers to provide some benefits that are now mandated.

While Republicans claim that repeal of Obamacare is necessary because the program is collapsing, the CBO report on the Republican plan reaffirms statements in previous reports that these Republican claims are false. The current Congressional Budget Office report states:

Although premiums have been rising under current law, most subsidized enrollees purchasing health insurance coverage in the nongroup market are largely insulated from increases in premiums because their out-of-pocket payments for premiums are based on a percentage of their income; the government pays the difference between that percentage and the premiums for a reference plan.

It also needs to be kept in mind that premiums for plans on the individual market typically had double digit increases annually prior to the passage of the Affordable Care Act, and that this is not a new problem created by Obamacare. Unlike insurance plans sold before Obamacare became law, current plans have limits on out of pocket expenses, no lifetime maximums, and cannot be cancelled by insurance companies when people became ill. Of course there also were no subsidies to assist with paying for the plans. It was also commonplace to have limited options and to see insurance companies leave markets prior to Obamacare.

The actual problem with Obamacare is that it did not go far enough. A public option or Medicare buy-in was necessary to provide more affordable care for those who do not obtain coverage through an employer or government plan. Expansion of Medicare to all would also have provided a more cost effective solution.

Vox looked at the likely effects on mortality should the Senate Republican plan pass, estimating that there will be 208,500 additional deaths over the next decade:

Drawing on that work, we estimate that if the Senate bill becomes law, 22,900 excess deaths will occur in 2020 — and the figure will grow over time. 26,500 extra deaths will take place in 2026. Over the next decade, we estimate that a total of 208,500 unnecessary deaths will occur if the law is passed (see Table 1).

We also calculate anticipated additional deaths, state by state, using state-level coverage losses for the year 2026 (see Table 2). The predicted excess deaths by state range from 30 in North Dakota to 2,992 in California in 2026 alone.

Some commentators have argued that it’s inappropriate — beyond the pale — to suggest that people will die as a result of this legislation. To the contrary, we contend that no debate over a health care policy can ignore evidence that it could have negative effects on health and mortality.

In making these calculations, we draw on the scientific literature demonstrating that expanding health insurance reduces deaths. We specifically apply the results of a particularly robust study of the effects of health care reform in Massachusetts on mortality. Massachusetts’ health care reform — which expanded Medicaid, offered subsidized private insurance, and included an individual mandate — famously served as a model for the ACA. The Massachusetts study looked at county-level mortality data in 2001 to 2005 (pre-reform) and 2007 to 2010 (post-reform), and compared the changes to carefully selected control groups in other states that had not enacted health reform.

Over 200,000 deaths is a high price to pay in order to provide tax cuts for the ultra-wealthy, which appears to be the major goal of the Republican plan.

Today we found that Donald Trump does not have any secretly recorded tapes of James Comey and the previously secret Senate Republican health care plan has been released. Neither was a surprise. If Trump had any tapes proving he was telling the truth, he would have already released them, and if there happened to be tapes which showed he was lying, he would never admit to having them. Also, as expected, the Senate plan includes deep cuts to Medicaid, decreases subside for lower income individuals, and increases costs for those who are older.

Simply put, if there’s a chance you might get sick, get old, or start a family – this bill will do you harm. And small tweaks over the course of the next couple weeks, under the guise of making these bills easier to stomach, cannot change the fundamental meanness at the core of this legislation.

I hope our Senators ask themselves – what will happen to the Americans grappling with opioid addiction who suddenly lose their coverage? What will happen to pregnant mothers, children with disabilities, poor adults and seniors who need long-term care once they can no longer count on Medicaid? What will happen if you have a medical emergency when insurance companies are once again allowed to exclude the benefits you need, send you unlimited bills, or set unaffordable deductibles? What impossible choices will working parents be forced to make if their child’s cancer treatment costs them more than their life savings?

To put the American people through that pain – while giving billionaires and corporations a massive tax cut in return – that’s tough to fathom. But it’s what’s at stake right now. So it remains my fervent hope that we step back and try to deliver on what the American people need.

It is far from certain that the Republicans can even pass this plan, despite using reconciliation so that they only need fifty votes. They can only afford to lose two votes, but four conservatives have already expressed reservations. From NPR:

Senate Republicans’ health care bill may already be on life support, with four key lawmakers announcing their opposition just hours after the GOP’s latest effort to repeal and replace the Affordable Care Act was released.

“Currently, for a variety of reasons, we are not ready to vote for this bill, but we are open to negotiation and obtaining more information before it is brought to the floor,” Sens. Rand Paul, R-Ky.; Ted Cruz, R-Texas; Mike Lee, R-Utah; and Ron Johnson, R-Wis., said in a statement Thursday afternoon.

They cannot easily move further to the right to appease the conservatives as some more moderate Republicans already have their own objections:

Sen. Dean Heller, R-Nev., who faces a competitive re-election race in 2018, says he has “serious concerns about the bill’s impact on the Nevadans who depend on Medicaid.”

“As I have consistently stated, if the bill is good for Nevada, I’ll vote for it and if it’s not — I won’t,” Heller said.

Annie Clark, a spokeswoman for Sen. Susan Collins, R-Maine, said the centrist has some misgivings about the bills as well.

Whether or not it passes, Republicans will now be able to tell their constituents that they have attempted to keep their promise to repeal and replace Obamacare. If their plan fails, the blame could be placed on Democrats and whichever Republicans vote against it, as opposed to the party as a whole. If that doesn’t work, McConnell could always take something from the Clinton playbook and blame Russia.

Mitch McConnell is aiming for a vote on the Senate health care plan before July 4. The Wall Street Journal reports:

Failure to take a vote before either the July 4 recess or the longer break later in the summer also could open Republican lawmakers up to pressure from constituents either concerned about losing their health coverage or expecting Republicans to follow through on pledges to repeal the law known as Obamacare. Some town-hall meetings during the spring, when the House was considering its legislation, saw lawmakers greeted by boisterous crowds.

GOP aides and others familiar with the negotiations said they anticipate the Senate bill’s text will be released later this week. The CBO is expected to release its estimate of the Senate bill’s impact on the federal budget and insurance coverage early next week, and a vote could potentially be held next Thursday, before lawmakers scatter.

As “mean” as the House plan was (to quote the inconsistent Donald Trump), reportedly the Senate plan might cut Medicaid spending even more. The Wall Street Journal notes that this “is likely to draw opposition from Republicans in states that expanded Medicaid under the ACA, including Sens. Rob Portman of Ohio, Dean Heller of Nevada and Shelley Moore Capito of West Virginia.”

Democrats, lacking the votes to stop the bill, are planning on using stalling tactics to attempt to slow down Senate business, but this is not likely to be sufficient to stop passage if the Republicans have the votes.

Polling has shown that voters are concerned about the cuts in health care benefits and the manner in which the bill is being drafted in secrecy, with voters preferring Obamacare to the Republican plan. Hopefully this will result in pressure on more vulnerable Republican Senators to vote against the bill.

Wednesday is also the deadline for insurance companies to decide upon whether they will participate in the exchanges under the Affordable Care Act and decide upon their rates. The uncertainty caused by the Republicans working in secrecy to change the law could scare more companies off and destabilize the plan regardless of whether Republicans succeed in repealing it.

Six members of the Presidential Advisory Council on HIV/AIDS (PACHA) have resigned in protest over the lack of concern by the Trump administration for treating HIV. They have publicly announced their decision in an open letter published in Newsweek. The letter notes that, “It is indisputable that the Affordable Care Act has benefitted people living with HIV and supported efforts to combat the HIV/AIDS epidemic.” It notes that, in contrast, provisions of the American Health Care Act which reduce access to health care “would be particularly devastating for people living with HIV.”

As advocates for people living with HIV, we have dedicated our lives to combating this disease and no longer feel we can do so effectively within the confines of an advisory body to a president who simply does not care.

The Trump Administration has no strategy to address the on-going HIV/AIDS epidemic, seeks zero input from experts to formulate HIV policy, and—most concerning—pushes legislation that will harm people living with HIV and halt or reverse important gains made in the fight against this disease.

Created in 1995, PACHA provides advice, information, and recommendations to the Secretary of Health and Human Services regarding programs, policies, and research to promote effective treatment, prevention, and an eventual cure for HIV.

Members, appointed by the President, currently include public health officials, researchers, health care providers, faith leaders, HIV advocates, and people living with HIV. PACHA also monitors and provides recommendations to effectively implement the National HIV/AIDS Strategy, which was created by the White House Office of National AIDS Policy in 2010 and revised in 2015.

The decision to resign from government service is not one that any of us take lightly. However, we cannot ignore the many signs that the Trump Administration does not take the on-going epidemic or the needs of people living with HIV seriously.

Signs of President Trump’s lack of understanding and concern regarding this important public health issue were apparent when he was a candidate. While Secretary Clinton and Senator Sanders both met with HIV advocates during the primaries, candidate Trump refused. Whatever the politics of that decision, Mr. Trump missed an opportunity to learn—from the experts—about the contours of today’s epidemic and the most pressing issues currently affecting people living with HIV.

In keeping with candidate Trump’s lack of regard for this community, President Trump took down the Office of National AIDS Policy website the day he took office and there has been no replacement for this website 132 days into his administration.

More important, President Trump has not appointed anyone to lead the White House Office of National AIDS Policy, a post that held a seat on the Domestic Policy Council under President Obama. This means no one is tasked with regularly bringing salient issues regarding this ongoing public health crisis to the attention of the President and his closest advisers.

By comparison, President Obama appointed a director to this office just 36 days into his administration. Within 18 months, that new director and his staff crafted the first comprehensive U.S. HIV/AIDS strategy. By contrast, President Trump appears to have no plan at all…

We believe he should embrace the important work accomplished by the National HIV/AIDS Strategy. Public health is not a partisan issue, and this important document could easily be ratified by the Trump Administration. If the President is not going to engage on the subject of HIV/AIDS, he should at least continue policies that support people living with and at higher risk for HIV and have begun to curtail the epidemic.

While these actions and others are gravely worrisome to us as HIV advocates, the final straw for us—more like a two-by-four than a straw—is President Trump’s handling of health care reform.

It is indisputable that the Affordable Care Act has benefitted people living with HIV and supported efforts to combat the HIV/AIDS epidemic. Gains in the percentage of people with HIV who know their status, the percentage engaged in care, the percentage receiving successful treatment, and a decrease in new cases of HIV were seen in Massachusetts under Romneycare. We are beginning to see similar effects on a national level under Obamacare.

People living with HIV know how broken the pre-ACA system was. Those without employer-based insurance were priced out of the market because of pre-existing condition exclusions. And “high risk pools” simply segregated people living with HIV and other health conditions into expensive plans with inferior coverage and underfunded subsidies—subsidies advocates had to fight for tooth-and-nail in every budgetary session.

For people living with HIV, that usually meant an AIDS diagnosis—making the disease more difficult and expensive to bring under control—before becoming eligible.

Between reinstating that paradox by defunding Medicaid expansion, imposing per-person caps on benefits, and/or block granting the program, the changes to Medicaid contemplated by the American Health Care Act would be particularly devastating for people living with HIV.

And we know who the biggest losers will be if states are given the option of eliminating essential health benefits or allowing insurers to charge people with HIV substantially more than others.

It will be people—many of them people of color—across the South and in rural and underserved areas across the country, the regions and communities now at the epicenter of the U.S. HIV/AIDS epidemic.

It will be young gay and bisexual men; it will be women of color; it will be transgender women; it will be low-income people.

It will be people who become newly infected in an uncontrolled epidemic, new cases that could be prevented by appropriate care for those already living with the disease.

While we are in agreement that the ACA needs to be strengthened to lower premiums, improve competition, and increase access to care, it makes no sense to dismiss gains made under the ACA just to score political points.

Experts with real facts, grounded in science, must be in the room when healthcare policy decisions are made. Those decisions affect real people and real lives. If we do not ensure that U.S. leadership at the executive and legislative levels are informed by experience and expertise, real people will be hurt and some will even die.

Because we do not believe the Trump Administration is listening to—or cares—about the communities we serve as members of PACHA, we have decided it is time to step down.

We will be more effective from the outside, advocating for change and protesting policies that will hurt the health of the communities we serve and the country as a whole if this administration continues down the current path.

We hope the members of Congress who have the power to affect healthcare reform will engage with us and other advocates in a way that the Trump Administration apparently will not.

The lie of the week is that the Republican-controlled Congress voted to repeal and replace Obamacare. Repeal yes, but the law they passed is too worthless to seriously be called a replacement. Republicans voted to deny health care coverage to millions, and to open the door for insurance companies to deny coverage for preexisting conditions. Doctors, insurance companies, hospitals, AARP, and many consumers groups are unified in opposing this legislation. Fortunately even some Senate Republicans realize that this is a terrible plan and want to start from scratch.

Could weaken employer sponsored health care along with plans sold on the exchanges, including removing coverage for the essential health benefits now in Obamacare, and removing prohibition on annual limits of coverage

The House plan could return us to the days when insurance companies made their profits by taking in premiums but finding ways to avoid paying out money on claims. Only selling insurance to the healthy very well could result in lower premiums, but this defeats the purpose of having health insurance. Republicans claim to be funding high risk pools to care for those with preexisting conditions, but they are only providing funding to cover five percent of those with preexisting conditions.

Of course, this will depend upon what happens in the states, and how many red states actually do opt out of the current requirements. Scott Walker has already stated he might apply for a waiver for coverage of preexisting conditions in Wisconsin.

Health care should dominate politics in upcoming cycles, but Democrats cannot count on this by itself being the key to retaking control of the House. Democrats need to keep up the pressure and do a far better job of making their arguments than they did when the Affordable Care Act was initially passed. It is questionable if anything resembling the House plan will ever pass the Senate and become law. (Presumably Donald Trump will sign whatever the Republicans pass, regardless of how much it violates his campaign promises).

Democrats could have the same problem in capitalizing on this as they did in promoting Obamacare. While some might lose insurance coverage immediately, many others might feel safe, not realizing that developing a medical problem could put them at risk of losing coverage in the future. Some will even be happy as young, healthy people very likely could wind up paying less–as long as they remain young and healthy. The adverse effects of this law won’t be fully apparent in 2018.

The Democrats could also lose due to their political cowardice. During the 2016 presidential campaign, Hillary Clinton opposed Bernie Sanders’ proposal for Medicare for All. Truthout debunked Clinton’s arguments. Now Nancy Pelosi and the Democratic establishment are refusing to take this opportunity to push for a single payer plan. The Observer’s view of Pelosi and mainstream Democrats is quite close to that expressed previously by Truthout:

Their failure to support a proposal that the majority of their base wants illuminates the growing disconnect between elected officials and their constituents and the massive influence of the health insurance and pharmaceutical industries. Americans want single payer health care, and the obstacles blocking them from the system they want are special interests, which are bought and paid for Democrats in office who avoid taking principled stances on issues. Democrats like Pelosi don’t stand for anything because fighting for something like single payer health care would upset the party’s wealthy donors.

Pelosi’s and other Democrats’ arguments excuse themselves from supporting progressive policies and reaffirm the Democratic Party as a corrupt entity tied to the wealthiest 1 percent of Americans. On May 1, the Washington Post reported a poll conducted in January among Trump voters who had previously voted for Obama. When those polled were asked what the Democratic Party stands for they gave responses like, “The 1 percent,” “The status quo” and “They’re for the party. Themselves and the party.” One woman, asked whether the Democratic Party is for people like her, flatly declared, “Nope.”

As Donald Trump has learned, health care is complicated. You cannot reduce costs without reducing coverage, unless you make fundamental changes in the system. The most obvious way would be a single payer plan which both removes the huge profits of the insurance industry and places everyone in the same risk pool. In hiding from this reality, Democrats show why they tend to lose and Republicans have been winning. Republicans did not care that their ideas have been far out of the mainstream. They pushed their ideas until they won over enough people to win, even if it has been on fallacious arguments. The party which stands for something, regardless of what it stands for, has an advantage over a party which stands for nothing. Thus we have seen the Democratic losses in 2010, 2014, and now 2016.

The nonpartisan Congressional Budget Office has projected that twenty-four million more Americans will wind up uninsured under the Republican health care plan (which calls into question whether this should be called a health care plan at all). The plan would provide inadequate funding for Medicaid, and risks destabilizing the individual market–unless you believe Republican predictions that the free market would respond with better products. This is rather hard to believe considering the failure of the market to handle insurance for those not receiving it through employer or government programs prior to the Affordable Care Act.

To put this in perspective, studies have projected that the loss of insurance by twenty million people (which is less than is predicted under the Republican plan) will result in 24,000 more deaths per year. This backs up the statement from Bernie Sanders that “thousands of Americans will die” if the Republican plan becomes law

According to the CBO, 64-year olds making $26,500 per year would see their premiums increase by an estimated 750 percent by 2026. While they are on track to pay $1,700 under the current law, the CBO projects the American Health Care Act would force them to pay $14,600. Even if you grant that inflation will allow them to make slightly more money by 2026, that’s still about half of their income going to health care.

There is additional information of significance. Despite Republican claims of a death spiral, the CBO report showed that the ACA is not “imploding.” As other studies have also found, it is stabilizing as more people obtain coverage:

Under current law, most subsidized enrollees purchasing health insurance coverage in the nongroup market are largely insulated from increases in premiums because their out-of-pocket payments for premiums are based on a percentage of their income; the government pays the difference. The subsidies to purchase coverage combined with the penalties paid by uninsured people stemming from the individual mandate are anticipated to cause sufficient demand for insurance by people with low health care expenditures for the market to be stable.

It looks like Republicans think that America has been demanding a new health care plan which will greatly reduce the number of people who are insured, increase costs for poor and older Americans, destabilize the individual insurance market, and cut taxes for the wealthy. While waiting for the CBO scoring, the Brookings Institute has made their calculations as to how terrible the Republican health care bill is, predicting that at least 15 million people will lose health care coverage:

There is significant uncertainty about exactly how CBO will model these provisions and how it will expect the various provisions to interact with one another. Nonetheless, we conclude that CBO’s analysis will likely estimate that at least 15 million people will lose coverage under the American Health Care Act (AHCA) by the end of the ten-year scoring window. Estimates could be higher, but it’s is unlikely they will be significantly lower.

Many will suffer from the cuts to Medicaid. Many of those who purchase private coverage on the exchanges will suffer because of how the subsidies are restructured, based on age as opposed to income and the actual costs of insurance. The Kaiser Family Foundation has posted projections regarding this.

Medical organizations and those representing the elderly including AARP, the American Medical Association and the American Hospital Association have objected to the Republican plan. AARP issued a statement opposing the “House plan that would make changes to our current health care system, such as shortening the life of Medicare, hiking costs for those who can least afford higher insurance premiums, risking seniors’ ability to live independently, and giving tax breaks to big drug companies and health insurance companies.”

The less affluent voters who backed Trump will be hurt by the changes. Of course some people do benefit. “Nearly everyone in the Top 1%, who earn more than $774,000 a year, would enjoy a hefty tax cut, averaging $33,000, according to the non-partisan Tax Policy Center. Those in the Top 0.1% would get an average tax cut of about $197,000.” Insurance companies also benefit:

Obamacare allowed insurance companies to deduct only $500,000 of their executives’ pay as a business expense. The GOP bill would repeal that limitation, starting in 2018.

Top insurers pay their leaders millions in compensation every year so this provision could mean a nice tax savings for the companies.

One excuse given by Republicans for repealing Obamacare is the increased cost of premiums. However, most people receive health care coverage through either government programs or employer programs, which have not had major increases in premiums. The individual market had frequent jumps in premiums, and that has continued, except under Obamacare most people receive subsidies to help cover this. As a consequence, only about three percent of the country is actually facing the increases in premiums which Republicans are using to justify their plan. In return, we receive more comprehensive coverage which cannot be denied based upon medical problems.

As one of the three percent who purchases health insurance without qualifying for subsidies, I certainly do not see the Republicans as doing me any favors. My premiums will be higher under the Republican plan than they are now, and the even bigger problem is that the plan may “threaten the stability of the individual market” per the Brookings report, possibly making it impossible to obtain coverage.

Of course if the goal is to call Obamacare a failure, then this was a smart move by Trump. The higher premiums are, the easier it is to criticize the plan.

What Donald Trump might not even understand is that the Affordable Care Act did not bring about insurance with high premiums, along with high deductibles and copays. Insurance on the individual market has always been like this for those of use who purchase our own insurance, as opposed to receiving insurance through employers or government plans. The difference is that, prior to Obamacare, people could purchase expensive, high deductible plans and then lose their coverage if they got sick. If they already had preexisting medical conditions, they would often be denied coverage, or have the reasons they need health care coverage be excluded from the plan. These problems no longer exist under the Affordable Care Act.

Republicans are meeting to discuss health care, with a goal of introducing legislation by late March for an alternative program. While President Trump and Republican Congressional leaders are talking about a quick repeal of Obamacare, The Washington Post reports that, behind closed doors, many Republicans are expressing concerns:

Republican lawmakers aired sharp concerns about their party’s quick push to repeal the Affordable Care Act inside a closed-door meeting Thursday, according to a recording of the session obtained by The Washington Post.

The recording reveals a GOP that appears to be filled with doubts about how to make good on a long-standing promise to get rid of Obamacare without explicit guidance from President Trump or his administration.

Senators and House members expressed a range of concerns about the task ahead: how to prepare a replacement plan that can be ready to launch at the time of repeal; how to avoid deep damage to the health insurance market; how to keep premiums affordable for middle-class families; even how to avoid the political consequences of defunding Planned Parenthood, the women’s health-care organization, as many Republicans hope to do with the repeal of the ACA.

In a survey conducted by The New England Journal of Medicine, most primary care physicians preferred making improvements to the Affordable Care Act and opposed repeal. Improvements supported by physicians included creating a public option similar to Medicare to compete with private plans, providing tax credits to people eligible for Medicaid to purchase private plans, and increasing the use of health savings accounts. There was less support for some good ideas such as expanding Medicare coverage to those 55 to 64 years of age. There was also less support for two of the ideas promoted by Republicans, shifting even more costs to consumers and reducing regulations on insurance companies by allowing them to sell insurance over state lines. (From or dealings with insurance companies, doctors know that they cannot be trusted, and regulation is needed.) From the report:

We found that in response to the question, “What would you like to see the federal policy makers do with the Affordable Care Act?,” 15.1% of PCPs indicated that they wanted the ACA to be repealed in its entirety. Responses varied according to the physicians’ self-reported political party affiliation; no Democrats wanted to see the ACA repealed, whereas 32.4% of Republicans did. Among physicians who reported voting for Trump, only 37.9% wanted the ACA repealed in its entirety. PCPs were less likely than the general public to want the law repealed. A Kaiser Family Foundation poll conducted after the election that used a question and response options similar to those in our survey showed that 26% of the general public wants the law repealed in its entirety

When asked about aspects of the ACA as it currently exists, the physicians we surveyed almost universally supported the insurance-market regulations that prohibit insurance companies from denying coverage or charging higher prices on the basis of preexisting conditions (95.1% stated that the prohibition was “very important” or “somewhat important” for improving the health of the U.S. population). There was also strong support for other key provisions of the law, including allowing young adults to remain on their parents’ insurance plan until 26 years of age (87.6%), providing tax credits to small businesses (90.8%) and tax subsidies to individuals (75.2%), and expanding Medicaid (72.9%). A lower proportion — just under half — favored the tax penalty for individuals who do not purchase insurance (49.5%)…

Although only 15% of PCPs want the ACA repealed, nearly three quarters (73.8%) favor making changes to the law. Physicians responded most favorably to policy proposals that might increase choice for consumers, such as creating a public option resembling Medicare to compete with private plans, providing tax credits to allow people who are eligible for Medicaid to purchase private health insurance, and increasing the use of health savings accounts. PCP Survey Responses Regarding Potential Health Reform.). Physicians responded most negatively to policies that would shift more costs to consumers through high-deductible health plans. Less than half were in favor of proposals to decrease insurance-market regulations (by allowing insurance companies to sell across state lines), require states to expand Medicaid, or expand Medicare to adults 55 to 64 years of age.

A new CNN poll shows the same finding as a recent Gallup poll which found that Donald Trump has record low approval for modern presidents:

Donald Trump will become president Friday with an approval rating of just 40%, according to a new CNN/ORC Poll, the lowest of any recent president and 44 points below that of President Barack Obama, the 44th president.

Following a tumultuous transition period, approval ratings for Trump’s handling of the transition are more than 20 points below those for any of his three most recent predecessors. Obama took the oath in 2009 with an 84% approval rating, 67% approved of Clinton’s transition as of late December 1992 and 61% approved of George W. Bush’s transition just before he took office in January 2001.

In contrast, Barack Obama is leaving office with a 58 percent favorability rating. While the news has been dominated by Republican plans to repeal Obamacare, an NBC News/Wall Street Journal poll shows that the Affordable Care Act is more popular than ever. This poll was conducted before today’s report from the Congressional Budget Office showing that repeal of Obamacare would result in millions of people losing their insurance and in increase in premiums:

The number of people who are uninsured would increase by 18 million in the first new plan year following enactment of the bill. Later, after the elimination of the ACA’s expansion of Medicaid eligibility and of subsidies for insurance purchased through the ACA marketplaces, that number would increase to 27 million, and then to 32 million in 2026.

Premiums in the nongroup market (for individual policies purchased through the marketplaces or directly from insurers) would increase by 20 percent to 25 percent—relative to projections under current law—in the first new plan year following enactment. The increase would reach about 50 percent in the year following the elimination of the Medicaid expansion and the marketplace subsidies, and premiums would about double by 2026.

On behalf of the physician and medical student members of the American Medical Association (AMA), I am writing regarding our ongoing commitment to reform of the health care system and potential legislative actions during the first months of the 115th Congress.

The AMA has long advocated for health insurance coverage for all Americans, as well as pluralism, freedom of choice, freedom of practice, and universal access for patients. These policy positions are guided by the actions of the AMA House of Delegates, composed of representatives of more than 190 state and national specialty medical associations, and they form the basis for AMA consideration of reforms to our health care system.

Health system reform is an ongoing quest for improvement. The AMA supported passage of the Affordable Care Act (ACA) because it was a significant improvement on the status quo at that time. We continue to embrace the primary goal of that law—to make high quality, affordable health care coverage accessible to all Americans. We also recognize that the ACA is imperfect and there a number of issues that need to be addressed. As such, we welcome proposals, consistent with the policies of our House of Delegates, to make coverage more affordable, provide greater choice, and increase the number of those insured.

In considering opportunities to make coverage more affordable and accessible to all Americans, it is essential that gains in the number of Americans with health insurance coverage be maintained.

Consistent with this core principle, we believe that before any action is taken through reconciliation or other means that would potentially alter coverage, policymakers should lay out for the American people, in reasonable detail, what will replace current policies. Patients and other stakeholders should be able to clearly compare current policy to new proposals so they can make informed decisions about whether it represents a step forward in the ongoing process of health reform.

We stand ready to work with you to continue the process of improving our health care system and ensuring that all Americans have access to high quality, affordable health care coverage.

While health care policy could likely a major impact of the all-Republican government, it received very little attention during the presidential campaign. This is partially due to the media’s preference to cover the horse race and scandal, Donald Trump making more noise on matters such as the Wall, and an extraordinarily poor campaign by Hillary Clinton which concentrated on stressing Trump’s negatives and avoiding issues. Democrats are now starting to speak out on health care. Chuck Schumer is trying to turn Trump’s slogan against him, warning that Republicans will “Make America Sick Again.” Hopefully they can provide a resistance beyond coming up with a slogan.

Democrats were successful in blocking George Bush when he attempted to partially privatize Social Security in his second term, and similarly have a chance of receiving public support in opposing Republican attempts to reduce health care coverage, including cuts in Medicare and Medicaid. Republicans are also getting jittery about health care legislation. They could safely please their constituents by voting to abolish Obamacare when Barack Obama was in office and they knew he would veto their efforts if it made it past a filibuster. Many now realize they will be held accountable for what happens, including if people lose coverage, and insurance costs continue to rise rapidly. The Committee For A Responsible Federal Budget, typically conservative on government spending, has outline the costs of repealing Obamacare, giving further reasons for Republicans to be cautious.

Donald Trump remains a huge wild care, having both promised to abolish Obamacare and to provide a plan to cover all Americans. So far he has given no meaningful specifics, talking primarily about health savings accounts and allowing insurance companies to sell insurance over state lines. Neither is a real plan. One point to Trump’s credit is that, while his major appointees have been from a very narrow group (primarily wealthy conservatives), he has spoken to a wider range of people. Zeke Emanuel, the architect of the Affordable Care Act, came out of a meeting with Trump expressing optimism, as reported by NPR. He believes Trump might seek to have a bipartisan bill after Republicans have complained about how Obamacare was passed by only Democrats. He also pointed out that some conservatives are pushing for “repeal and replace” as opposed to the currently discussed tactic of “repeal and delay” and discussed how legislation might be handled after an initial resolution (even if along party lines) to abolish the ACA utilizing budget reconciliation:

And so that you really do need to repeal and replace, and you need to do it in one bill. Otherwise, you’re really going to disrupt the individual insurance market in a very bad way, and you’ll be responsible for millions of people losing their coverage but also health insurance premiums going up. And I think that is not a scenario that a lot of Republicans really want…

So one possibility is that they pass a resolution saying that they will then come back and pass a bill that will repeal parts of the Affordable Care Act and at the same time have a replacement for those parts of the Affordable Care Act…

The resolution can be party lines, but the bill would then have to construct both the repeal part but simultaneously the replacement part. And I think if you do it that way, you could begin to negotiate with Democrats. If you just have a repeal and we’ll be back in three years and tell you how we’re going to fix it, then the Democrats are simply going to walk away. Chuck Schumer has made that clear.

And they should walk away because then it’s all – it’s the old pottery barn principle that Colin Powell made famous, which is, you break it; you have to fix it, and you take responsibility. And the Democrats will not want their fingerprints anywhere near the breaking of Obamacare and the disruption of the insurance industry in the United States…

The question is, what is the shape of that bill? Is it just a repeal bill, or is it a repeal with replacement? And that negotiation about that bill could take several months. My own estimate is if both sides come with good faith, they could probably hammer this out in about six months. It’s not a small item. I mean health care reform is big.

The question is, what are the gives and takes? I do think – again, one of the reasons I’m optimistic is that when you look at conservative and liberal health policy experts, there’s about 70 or 80 percent overlap between the two groups about the shape of the future and what you would need. And I think that’s, again, why I’m optimistic – because there aren’t that many ways of doing health care reform. They’re really limited.